Cervical or intrathoracic: JAMA study finds optimal location for esophagogastric anastomosis for esophagectomy

Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. In the last decade, minimally invasive esophagectomy (MIE) has been shown to be superior compared with open esophagectomy regarding postoperative outcomes, without compromising oncologic safety. Although not all surgeons are convinced of the benefits of MIE (eg, MIE has also been associated with increased complication rates in registries), it has led to many surgeons implementing transthoracic MIE with cervical anastomosis, because minimally invasive creation of an intrathoracic anastomosis is considered more challenging.

" To our knowledge, no randomized clinical trial has compared the outcome of intrathoracic anastomosis vs cervical anastomosis after transthoracic MIE. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE." the research team quoted.

Researchers aimed to compare an intrathoracic with a cervical anastomosis in a randomized clinical trial. This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020.

Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis. The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life.

Data analysis revealed some interesting facts.

• Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, −19.4% [95% CI, −29.5% to −9.3%]).
• Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, −21.9% [95% CI, −32.1% to −11.6%]).
• Intensive care unit length of stay, mortality rates, and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, −11.3% [−20.4% to −2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, −7.3% [95% CI, −12.1% to −2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, −12.2 [95% CI, −19.6 to −4.7]; problems of choking when swallowing, −10.3 [95% CI, −16.4 to 4.2]; trouble with talking, −15.3 [95% CI, −22.9 to −7.7]).

"Future research will be needed to evaluate to what extent broad implementation of transthoracic MIE with intrathoracic anastomosis will lead to improved patient outcomes and assess long-term functional and oncological outcome between patients with intrathoracic and cervical anastomosis after transthoracic MIE."the team concluded.

For full article follow the link: 10.1001/jamasurg.2021.1555

Primary source: JAMA Surgery